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A management strategy for pathological lymphadenopathy detected on mammography
ABSTRACTS
359
Posters
and is a major source of morbidity. T h e mammographic features of 91 benign lesions excised during the screening programme were analysed:
THE I M P O R T A N C E OF THE ACCURATE M E A S U R E M E N T OF BREAST T U M O U R SIZE IN THE DECISION TO OFFER BREAST CONSERVATION H. C. BURRELL, D. M. S1BBERING, 1. O. ELLIS, C. W. ELSTON, J. F. R. ROBERTSON, R. W. BLAMEY, A. J. EVANS and A. R. M. WILSON
41% Suspicious calcifications (non-comedo type) 20% Poorly-defined masses 17% Parenchymal deformities 16% Well-defined masses
City Hospital, Nottingham T u m o u r size is an important factor in determining the suitability of a breast cancer for treatment with breast conservation. In this unit 3 cm is the size limit used for advising such treatment. Its accurate measurement is therefore essential to offer conservation when appropriate to the maximum number of women. In 45 palpable breast cancers, the tumour size measured by clinical palpation, ultrasound and mammography was compared to the pathological size (fresh specimen) after surgical removal.
Modality
Clinical Mammography Ultrasound
Comparison with pathological size Over-estimate
Under-estimate
Within 3 mm*
Most accurate
30 (67)t 15 (35) 10 (22)
1 (2) 3 (7) 6 (13)
14 (31) 25 (58) 29 (65)
11 (24) 23 (51) 17 (38)
* 3 mm represents a 10% error when 3 cm is used as the size limit for breast conservation. t Numbers in parentheses are percentages. Mammographic size was the most accurate modality in over half of the cases. Clinical measurement over-estimated the size in two thirds of the cases. Both ultrasound and mammography were within 3 mm in over half of the cases. Six patients (I 3 %) had tumours that were larger than 3 cm on palpation, but were correctly measured under 3 cm by ultrasound and mammography. These patients were denied breast conservation as clinical size alone was used to assess tumour size. This study illustrates the importance o f radiological imaging as well as clinical palpation in the accurate assessment of tumour size.
A M A N A G E M E N T STRATEGY FOR P A T H O L O G I C A L L Y M P H A D E N O P A T H Y DETECTED ON M A M M O G R A P H Y K. LYONS, S. MORRIS, K. H O R G A N , L. M O R U S and !. HAJJ
Department of Radiodiagnosis, University Hospital of Wales, Cardiff" Axillary and intramammary lymph nodes are frequently imaged on mammography. Abnormal looking lymph nodes (enlarged, round or dense) constitute a diagnostic difficulty because they could be the only indicator of an occult breast cancer or a sign of systemic benign or malignant disease. Our management strategy is described using illustrated examples. Unilateral pathological lymphadenopathy in the absence of a mammographically-detected breast mass of infection would require ultrasound examination to provide further architectural information on nodal status, followed by guided fine needle aspiration cytology (FNAC) to increase the specificity of the diagnosis. Bilateral pathological lymphadenopathy is highly suggestive of a systemic disorder. An ultrasound-guided FNAC can be helpful in deciding whether further investigation is required, such as in lymphoma, rheumatoid arthritis and sarcoidosis. A clear management strategy for mammographically-detected lymphadenopathy is important and may avoid unnecessary delays in diagnosis.
AN ANALYSIS OF BENIGN LESIONS DURING T H E N O T T I N G H A M BREAST SCREENING P R O G R A M M E N. SPENCER, A. J. EVANS, M. SIBBERING, M. GALEA, G. T U R N E R and A. R. M. WILSON
Helen Garrod Breast Screening Unit and Department of Surgery. City Hospital, Nottingham The excision of benign lesions during a breast screening programme is unavoidable. This contributes significantly to the cost of the programme
8% Suspicious calcifications (comedo type) 4% Spiculate masses 4% Asymmetric density (all had other features} 1% Developing density
We have used the positive predictive value (PPV) for malignancy (derived from analysis of all our marker biopsies) of different mammographic features and F N A results to try and reduce our benign biopsies. The PPV for well-defined masses was 0%, so these are no longer recalled. The PPV for parenchymal deformities was 41% but FNA was unable to help us excise them all as 33% of deformities with a benign FNA were malignant. Suspicious (non-comedo type) calcifications, the commonest cause of a benign biopsy, had a PPV of 35%. Again, a single benign FNA result only reduced the PPV to 28%. Improved radiological discrimination, multiple FNAs and needle histology are possible avenues to improved open biopsy selection in this group. TIME FOR CHANGE IN A&E: PATELLA FRACTURES L. WILKINSON, K. PETERS, N. RIDLEY and G. DE LACEY
Department of Diagnostic Radiology, Northwick Park" Hospital, Harrow Patella fractures are relatively common injuries, and may lead to significant long-term problems if precise reduction is not achieved. Four cases are presented which illustrate that a patella fracture may not be evident on standard AP and lateral views. A survey of 40 A&E radiography departments indicates that there is no standard practice for radiography following an injury to the patella. We recommend that skyline and lateral views should be performed in all cases where there is strong cli,nical suspicion of a patella fracture in which no injury is detected on the standard AP and lateral views.
A C O M P A R I S O N OF T W O MRI PULSE S E Q U E N C E S FOR 3-D RECONSTRUCTION OF THE LIVER J. C U L L I N G W O R T H , J. W A R D , q . R I D G E W A Y and P. J. ROBINSON
M R I Unit, St James ~ UniversiO' Hospital, Leeds 3-D display of segmental anatomy and vascular landmarks may be helpful in surgical planning of liver tumour resection. Tl-weighted SE images have a high signal-to-noise ratio but Gd-enhanced G R E images show the vessels more effectively. Which sequence is better for 3-D mapping? Method: In l0 patients we acquired TlwSE (TR = 500, TE = 15) and Gd-enhanced G R E ( T R = 135, T E = 4 ) images using a 1.0 T unit (Siemens). Both methods included 15 slices of 5 mm thickness through the porta hepatis. Segmentation of the liver surface, tumour margins and main veins was performed on a 3-D work station (Allegro ISG). Two independent observers scored each set of images for the continuity and extent of the venous structures and the ability to segmentally localize the lesions. Results: In 8/10 patients both sequences showed all the main veins. In 2/10 patients the left main hepatic vein was seen on TIwSE but not on Gd-enhanced GRE. One patient had multiple lesions in several segments, and one patient had no lesion. 8/10 patients had lesions which required segmental localization; this was achieved in 7/8 cases With TlwSE and 8/8 Gd-GRE. o n e observer subjectively preferred T I w S E images in 8/10 cases, the other observer preferred T1 wSE images in 9/10 cases.
Conclusion: Both sequences allow 3-D display of the vessels. T I w S E images achieved slightly better observer scores but the difference was not statistically significant. Both sequences are suitable for 3-D display of lesions and segmental anatomy. PRIMARY R E T R O P E R I T O N E A L LIPOSARCOMA: CORRELATION OF H E T E R O G E N E O U S CT M O R P H O L O G Y W I T H H I S T O P A T H O L O G I C A L FINDINGS IN 5 CASES E. MOSKOVIC, J. M. THOMAS*, A. C H A K R A B A R T Y t and C. F I S H E R t
Departments of Radiology, *Surgery and t Histopathology, Sarcoma Unit, Royal Marsden Hospital, London Introduction: Primary retroperitoneal liposarcomas often achieve large sizes before diagnosis, and may demonstrate a spectrum of pathological types within the overall tumour mass. These are broadly classified into
359
Posters
and is a major source of morbidity. T h e mammographic features of 91 benign lesions excised during the screening programme were analysed:
THE I M P O R T A N C E OF THE ACCURATE M E A S U R E M E N T OF BREAST T U M O U R SIZE IN THE DECISION TO OFFER BREAST CONSERVATION H. C. BURRELL, D. M. S1BBERING, 1. O. ELLIS, C. W. ELSTON, J. F. R. ROBERTSON, R. W. BLAMEY, A. J. EVANS and A. R. M. WILSON
41% Suspicious calcifications (non-comedo type) 20% Poorly-defined masses 17% Parenchymal deformities 16% Well-defined masses
City Hospital, Nottingham T u m o u r size is an important factor in determining the suitability of a breast cancer for treatment with breast conservation. In this unit 3 cm is the size limit used for advising such treatment. Its accurate measurement is therefore essential to offer conservation when appropriate to the maximum number of women. In 45 palpable breast cancers, the tumour size measured by clinical palpation, ultrasound and mammography was compared to the pathological size (fresh specimen) after surgical removal.
Modality
Clinical Mammography Ultrasound
Comparison with pathological size Over-estimate
Under-estimate
Within 3 mm*
Most accurate
30 (67)t 15 (35) 10 (22)
1 (2) 3 (7) 6 (13)
14 (31) 25 (58) 29 (65)
11 (24) 23 (51) 17 (38)
* 3 mm represents a 10% error when 3 cm is used as the size limit for breast conservation. t Numbers in parentheses are percentages. Mammographic size was the most accurate modality in over half of the cases. Clinical measurement over-estimated the size in two thirds of the cases. Both ultrasound and mammography were within 3 mm in over half of the cases. Six patients (I 3 %) had tumours that were larger than 3 cm on palpation, but were correctly measured under 3 cm by ultrasound and mammography. These patients were denied breast conservation as clinical size alone was used to assess tumour size. This study illustrates the importance o f radiological imaging as well as clinical palpation in the accurate assessment of tumour size.
A M A N A G E M E N T STRATEGY FOR P A T H O L O G I C A L L Y M P H A D E N O P A T H Y DETECTED ON M A M M O G R A P H Y K. LYONS, S. MORRIS, K. H O R G A N , L. M O R U S and !. HAJJ
Department of Radiodiagnosis, University Hospital of Wales, Cardiff" Axillary and intramammary lymph nodes are frequently imaged on mammography. Abnormal looking lymph nodes (enlarged, round or dense) constitute a diagnostic difficulty because they could be the only indicator of an occult breast cancer or a sign of systemic benign or malignant disease. Our management strategy is described using illustrated examples. Unilateral pathological lymphadenopathy in the absence of a mammographically-detected breast mass of infection would require ultrasound examination to provide further architectural information on nodal status, followed by guided fine needle aspiration cytology (FNAC) to increase the specificity of the diagnosis. Bilateral pathological lymphadenopathy is highly suggestive of a systemic disorder. An ultrasound-guided FNAC can be helpful in deciding whether further investigation is required, such as in lymphoma, rheumatoid arthritis and sarcoidosis. A clear management strategy for mammographically-detected lymphadenopathy is important and may avoid unnecessary delays in diagnosis.
AN ANALYSIS OF BENIGN LESIONS DURING T H E N O T T I N G H A M BREAST SCREENING P R O G R A M M E N. SPENCER, A. J. EVANS, M. SIBBERING, M. GALEA, G. T U R N E R and A. R. M. WILSON
Helen Garrod Breast Screening Unit and Department of Surgery. City Hospital, Nottingham The excision of benign lesions during a breast screening programme is unavoidable. This contributes significantly to the cost of the programme
8% Suspicious calcifications (comedo type) 4% Spiculate masses 4% Asymmetric density (all had other features} 1% Developing density
We have used the positive predictive value (PPV) for malignancy (derived from analysis of all our marker biopsies) of different mammographic features and F N A results to try and reduce our benign biopsies. The PPV for well-defined masses was 0%, so these are no longer recalled. The PPV for parenchymal deformities was 41% but FNA was unable to help us excise them all as 33% of deformities with a benign FNA were malignant. Suspicious (non-comedo type) calcifications, the commonest cause of a benign biopsy, had a PPV of 35%. Again, a single benign FNA result only reduced the PPV to 28%. Improved radiological discrimination, multiple FNAs and needle histology are possible avenues to improved open biopsy selection in this group. TIME FOR CHANGE IN A&E: PATELLA FRACTURES L. WILKINSON, K. PETERS, N. RIDLEY and G. DE LACEY
Department of Diagnostic Radiology, Northwick Park" Hospital, Harrow Patella fractures are relatively common injuries, and may lead to significant long-term problems if precise reduction is not achieved. Four cases are presented which illustrate that a patella fracture may not be evident on standard AP and lateral views. A survey of 40 A&E radiography departments indicates that there is no standard practice for radiography following an injury to the patella. We recommend that skyline and lateral views should be performed in all cases where there is strong cli,nical suspicion of a patella fracture in which no injury is detected on the standard AP and lateral views.
A C O M P A R I S O N OF T W O MRI PULSE S E Q U E N C E S FOR 3-D RECONSTRUCTION OF THE LIVER J. C U L L I N G W O R T H , J. W A R D , q . R I D G E W A Y and P. J. ROBINSON
M R I Unit, St James ~ UniversiO' Hospital, Leeds 3-D display of segmental anatomy and vascular landmarks may be helpful in surgical planning of liver tumour resection. Tl-weighted SE images have a high signal-to-noise ratio but Gd-enhanced G R E images show the vessels more effectively. Which sequence is better for 3-D mapping? Method: In l0 patients we acquired TlwSE (TR = 500, TE = 15) and Gd-enhanced G R E ( T R = 135, T E = 4 ) images using a 1.0 T unit (Siemens). Both methods included 15 slices of 5 mm thickness through the porta hepatis. Segmentation of the liver surface, tumour margins and main veins was performed on a 3-D work station (Allegro ISG). Two independent observers scored each set of images for the continuity and extent of the venous structures and the ability to segmentally localize the lesions. Results: In 8/10 patients both sequences showed all the main veins. In 2/10 patients the left main hepatic vein was seen on TIwSE but not on Gd-enhanced GRE. One patient had multiple lesions in several segments, and one patient had no lesion. 8/10 patients had lesions which required segmental localization; this was achieved in 7/8 cases With TlwSE and 8/8 Gd-GRE. o n e observer subjectively preferred T I w S E images in 8/10 cases, the other observer preferred T1 wSE images in 9/10 cases.
Conclusion: Both sequences allow 3-D display of the vessels. T I w S E images achieved slightly better observer scores but the difference was not statistically significant. Both sequences are suitable for 3-D display of lesions and segmental anatomy. PRIMARY R E T R O P E R I T O N E A L LIPOSARCOMA: CORRELATION OF H E T E R O G E N E O U S CT M O R P H O L O G Y W I T H H I S T O P A T H O L O G I C A L FINDINGS IN 5 CASES E. MOSKOVIC, J. M. THOMAS*, A. C H A K R A B A R T Y t and C. F I S H E R t
Departments of Radiology, *Surgery and t Histopathology, Sarcoma Unit, Royal Marsden Hospital, London Introduction: Primary retroperitoneal liposarcomas often achieve large sizes before diagnosis, and may demonstrate a spectrum of pathological types within the overall tumour mass. These are broadly classified into